Highland Hospital Department of Emergency Medicine Visiting

Highland Hospital
Department of Emergency Medicine
Visiting Elective Scholarship Program (VESP)
Application for the Highland Hospital Emergency Medicine VESP
Please submit the following materials:
Completed VESP application (see next page)
Leadership and Research Experience
Background
Personal Statement
Completed VSAS (Visiting Student Application Service) application to the Highland Hospital Emergency Medicine Clerkship EM: 140.40, including all requirements as detailed in the application.
Submit all VESP application materials by mail or email to:
Highland Hospital Emergency Medicine Visiting Elective Scholarship Program
Dr. Caitlin Bailey, MD
c/o Jackie Alberto
Highland Hospital, Alameda Health System
Department of Emergency Medicine
Room 6412
1411 East 31st Street
Oakland, CA 94602
Email: [email protected]
For email please specify in the subject that this is the scholarship application.
Thank you!
Highland Hospital Emergency Medicine VESP APPLICATION FORM
(To type your information on this page, use your mouse to go to the grey box on the form. Enter text, or use your mouse to click the appropriate check box.) The Applicant:
Last Name
First Name Current address
City
State
Permanent address
Birth date Zip City
State
Zip Primary Email
Alternate Email Home Telephone
Gender:
Mobile Phone
Female
Male Sexual Orientation: (OPTIONAL)
Specify only if you choose to share this information. Not required.
Your Current Medical School: Current Year at your Medical School (please check one)
3 4 Other: please specify: Expected Date of Graduation: Citizenship:
U.S. Citizen
U.S.
U.S. Noncitizen National
Do you have a Social Security Number? Permanent Resident of Yes
No Do you have a disability? (physical or mental impairment that substantially limits one or more major life activities)
*Yes
No
Do not wish to provide
*If disabled, which of the following describes your disability(ies)?
Hearing
Visual
Disadvantaged Background: Mobility Other: Yes No
IF YES, please check category:
Family with an annual income below established low­income thresholds. Social, cultural, or educational environment such as that found in certain rural or inner­ city environments that have demonstrably and recently directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a medical career. First Generation in Family to Attend College: Yes No Race/Ethnicity: What is your racial background? (OPTIONAL. Check all that apply.)
African American/Black
Native­born Black American African (origin in black racial group)
Haitian
West Indian
Asian Bangladeshi
Burmese/Myanmarese
Chinese
Filipino
Indian
Indonesian
Japanese
Korean
Laotian
Malaysian
Nepali
Pakistani
Sri Lankan
Thai
Vietnamese
Other Asian, specify Caucasian or White (of Europe, North Africa, or the Middle East)
Hispanic/Latino Central American
Mexican Cuban
South American, specify Puerto Rican
Other Hispanic, specify Native American
American Indian Native Alaskan
Native Hawaiian
Pacific Islander Fijian
Guamanian
Marshalleses
Melanesians
Micronesians
Polynesians Samoan
Tahitian
Tongan
Other Pacific Islander, specify Prefer not to disclose
How did you learn about our program? (Please answer with only a few sentences)
Leadership or Research Experience or Publications
List and very briefly describe prior leadership and research experience with dates, if any, and any articles/abstracts published in referred journals. (Attach additional sheet if necessary and please list in a CV format). A complete CV is also welcome.
Personal Statement Applicant: Either cut and paste or type directly into the grey box below. (Not to exceed 500 words)
Instructions: Please describe how your background has influenced the type of physician you want to be and the type of communities that you want to serve. Please also include any experience in working with diverse communities and future plans upon completing residency training. Finally, in a very brief paragraph include a few sentences about your interest in Emergency Medicine.
A statement of need: In less than 250 words please explain how this scholarship will benefit you.